It is heading toward its tenth anniversary, an occasion that does not look to be happy. Supposedly the President’s signature accomplishment, it is now a millstone around his legacy. And deservedly so, since he and the Congress that passed the law at a minimum were reckless, and more likely intentionally lied to people, about the consequences of so monumental an attempt to reshape the health insurance and health care systems. Lets start with one of the more visible, although not necessarily the most significant, of its provisions–the individual mandate and the insurance exchanges. Supposedly, coupled with the Medicaid expansion, the mandate would cover most of the uninsured, largely through use of competitive health coverage available through the exchanges. We also were promised that premiums would actually be lower. Despite warnings from experts that the exchanges as designed were likely to fail, due to a typical cost spiral, Congress pressed ahead. The result is that for 2017, less than half the people projected are covered through exchanges, premiums are growing rapidly, and, in some places, there is literally no competition on the exchanges. And many individuals have clearly either figured out how to evade the penalty for not being insured or are choosing to pay it rather than buy expensive, poor benefit, policies. A lot of young, healthy people simply don’t see why they should pay a huge price for coverage they won’t use, and quite rightly.
The Medicaid expansion, on the other hand, is covering more people than expected, because who wouldn’t want basically free, extremely benefit-rich coverage. The problem is that the average cost per person is higher than projected and neither the federal government nor most states can afford the program. Although it hasn’t yet crashed like the exchanges and the individual mandate have, expect the crunch in a couple of years, when the cost begins to shift to the states. And the Medicaid expansion exposes a fundamental conflict and flaw in the system. Why do people who aren’t paying anything, and who often have bad health behaviors, getting free coverage for everything, while taxpayers often have to pay a lot in premium and cost-sharing for their health plans and they get to pay the taxes for Medicaid coverage. There is nothing fair about that, and it will become a real sore point. All the money spent to encourage more health care information technology use has obviously done little to improve quality or to lower costs. In fact, in some cases HIT appears to have the opposite effect. And it is making many doctors even less satisfied with their work. A number of the law’s provisions have accelerated vertical and horizontal consolidation among providers, which research pretty clearly shows is raising unit prices and overall health spending. So other than all these problems, that reform law has just done a wonderful job of fixing health care in America, as promised.